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Practice Uncertainties

Does ursodeoxycholic acid improve perinatal outcomes in women with intrahepatic cholestasis of pregnancy?

BMJ 2018; 360 doi: (Published 01 February 2018) Cite this as: BMJ 2018;360:k104
  1. Lucy C Chappell, National Institute for Health Research professor in obstetrics1,
  2. Jenny Chambers, founder and chair of ICP Support,2,
  3. Jim G Thornton, professor of obstetrics and gynaecology3,
  4. Catherine Williamson, professor of obstetric medicine1
  1. 1Women’s Health Academic Centre, King’s College London, London, UK
  2. 2ICP Support, Sutton Coldfield, UK
  3. 3Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
  1. Correspondence to L Chappell lucy.chappell{at}

What you need to know

  • Women with intrahepatic cholestasis of pregnancy are at higher risk of adverse perinatal outcomes such as fetal distress, spontaneous preterm birth, and stillbirth

  • Ursodeoxycholic acid is considered safe and effective to offer to improve maternal itching, but its use is off-licence and there is insufficient evidence that it improves perinatal outcomes

  • Monitor liver function tests weekly and offer referral to an obstetrician to discuss timing of admission for delivery in a hospital maternity unit

Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis, is the commonest primary liver disorder in pregnant women.1 It is characterised by itching (or pruritus) in the absence of a rash (fig 1) and raised concentrations of maternal bile acid (normal range 0-10 µmol/L).2 ICP affects around 0.7% of pregnancies in the UK.3 It is usually seen in the second half of pregnancy and is more common in women with a family history of the disease, a multi-fetal pregnancy, assisted reproductive treatment, higher maternal age, and certain ethnic groups, including Asian (Pakistani and Indian),4 Chilean, and indigenous American.5

Fig 1

Scratch marks, without rash, on the arm of a woman with ICP

The symptom of itching can be intensely unpleasant for the woman and gestational cholestasis has implications for the future health of the mother,6 however, the principal concern during pregnancy is the risk of adverse perinatal outcomes for the baby. Reports from case series and cohort studies describe increased perinatal risks, including spontaneous preterm labour, meconium staining, and intrapartum fetal distress.7 A prospective Swedish cohort study of 505 women with pruritus and raised maternal bile acids reported that the probability of fetal complications did not increase until bile acid concentrations were ≥40 µmol/L and increased by 1%–2% per additional 1 µmol/L of serum bile acids.8 More recently, a UK-wide case …

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